A healthcare provider organization that provides a patient with healthcare services (e.g., diagnostic X-Ray), sends claim information to a payer organization (e.g., a patient medical insurer) with a request for reimbursement. A payer organization requires formatting the claim information in a specific format using rules and guidelines provided by standards groups, such as ANSI (American National Standards Institute) X12 standards for EDI (Electronic Data Interchange) transactions or associated with a UB04 transaction form from the NUBC (National User Billing Committee), for example. A payer organization may require change of a mandatory format of a claim transaction form so that a number of versions of claims transactions and claims forms exist that are tailored to requirements of a payer organization. The customization of a claim transaction form having a standard format is burdensome especially if a format change is required. A payer organization may require different information for specific fields, depending on provided hospital services, for example and involve payer organization specific rule changes. Further, during implementation of such changes to correct billing programs, a payer organization may reject incomplete claims which causes cash flow delays to a healthcare provider.
Known systems support limited validation of claim transaction processing rules and are hampered by restrictions in assessing the effect of processing rule changes on claim data. Some known systems provide a facility for format certification, however, a claim that passes such certification may not be valid and compatible with specific payer organization rules, because the format certification verification process is not capable of sophisticated reimbursement calculations and format takes precedence over associated operation instruction. Known systems are typically not capable of calculating reimbursement and submitting processed data as claims forms or as EDI transactions without adversely compromising a regular claims production system. A system according to invention principles addresses these deficiencies and related problems.